Inspection·August 10, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/07/23 at 11:08 A.M., observation/interview with Resident #9 revealed she had not been changed since night shift and she was really wet. Resident #9 reported she had her call light on for a while and asked to verify it was working. On 08/07/23 at 11:15 A.M., interview with State Tested Nursing Assistant (STNA) #114 answered the light call light and verified the resident was saturated with urine and had not been provided incontinence care since night shift ending at 6:00 A.M. On 08/07/23 at 11:18 A.M., observation of STNA #114 after exiting Resident #9's room revealed she yelled down the hallway to STNA #163 using Resident #9's name and stated she was soaked from head to toe. STNA #114 verified at the time of the observation the resident was not being treated in a dignified manner and other residents and visitors were able to hear. This deficiency represents non-compliance investigated under Complaint Number OH00144024. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 2 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, and facility policy review, the facility failed to ensure a resident's (Resident #18) call light was kept within reach. The deficient practice affected one resident (Resident #18) of one reviewed for call lights. The facility census was 44. Residents Affected - Few Findings Include: Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, generalized muscle weakness, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs), including bed mobility, transfers, dressing, and toileting. Resident #18 had functional limitations and range of motion impairments on both sides of both upper and lower extremities. Review of the care plan, revised 08/07/23, revealed Resident #18 had potential for a decline of self-care and mobility, feeding, chewing and swallowing, bowel and bladder function, and communication related to Parkinson's Disease. Interventions included to keep call light in reach at all times. Observations on 08/07/23 at 12:43 P.M., 08/08/23 at 10:01 A.M., and 08/09/23 at 8:53 A.M. of Resident #18 in her room. Resident #18's call light was observed attached to her gown near her upper chest area with her arms laying by her sides twice and was observed sitting on top of her pillow on her bed behind her when Resident #18 was sitting up in her wheelchair next to the bed. This surveyor asked Resident #18 at the time of each observation if she was able to press her touch pad call light. Resident #18 attempted to find the call light attached to her gown but was not able to do so. Interview on 08/07/23 at 12:34 P.M. with Resident #18 and Resident #18's daughter revealed Resident #18 had range of motion impairments to both arms. Resident #18 had difficulty raising her arms up or moving her arms from side to side. Resident #18 stated she was able to press her touch pad call light as long as it was placed under or beside one of her hands. Interview on 08/09/23 at 8:53 A.M. with Resident #18 revealed she had pressed her call light a few times in the last couple of days when she could find it. Resident #18 stated she hollered for help if she was not able to find her call light. Observation and interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed Resident #18's call light was placed on her pillow on her bed behind her when the resident was up in her wheelchair next to her bed and was not within reach. STNA #146 confirmed Resident #18 was able to press her touch pad call light for assistance. Review of the facility policy, Call Light-Answering, undated, revealed the policy stated, it is the facility policy for all facility personnel to follow the guidelines below to respond to the resident's requests and needs. Ask the resident to return demonstration so that you will be sure that the resident can operate the system. When the resident is in bed or confined to a chair be sure the call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 3 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 light is within easy reach of the resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 4 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and facility policy review, the facility failed to clarify conflicting code statuses for one resident (#20). This affected one of five residents reviewed for advance directives. The facility census was 44. Findings Include: Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar disorder, contracture of left hand and contracture of left wrist. Review of the Do Not Resuscitate (DNR) Comfort Care form dated 07/13/21 revealed the resident elected to have the code status DNR comfort care arrest do not incubate. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the Nurse Practitioner (NP) progress note dated 07/27/23 revealed the NP documented the resident was a full code since 08/30/22. Review of the medical record revealed no physician's orders or plan of care for the resident's code status. 08/08/23 04:01 PM interview with Registered Nurse (RN) #131 verified the NP progress note documented the resident as a full code. RN #131 revealed she would treat the resident as a full code related to the conflicting documentation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 5 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interview, and facility policy review, the facility failed to notify one resident's (Resident #146) physicians when STAT (immediate) labs were not completed as ordered. The deficient practice affected one (Resident #146) of one reviewed for notification. The facility census was 44. Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. Review of the physician orders for August 2023 revealed Resident #146 had the following orders: STAT WBC (white blood cell) dated 08/03/23 and STAT CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) dated 08/05/23. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living (ADL). Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds. Review of the progress notes revealed on 08/03/23 at 2:33 P.M., the Assistant Director of Nursing (ADON)/Wound Nurse (WN) #131 documented wound rounds were completed with Wound Physician (WP) #108. There was concern over resident's left foot. STAT WBC was ordered. On 08/06/23 at 12:25 P.M., a note indicated, spoke to lab at this time regarding STAT labs that were put into the system. They stated they had no coverage for this STAT lab and labs were to be drawn on 08/07/23 in the morning. Review of lab results for Resident #146 revealed labs were collected on 08/04/23 and 08/07/23 respectively. There were not any additional notes indicating the physicians were notified when the STAT labs were not completed as ordered. Review of the care plan dated 07/28/23 revealed Resident #146 had a wound infection. Interventions included obtain and report diagnostic testing and lab work per order. Interview on 08/10/23 at 8:45 A.M. with Certified Nurse Practitioner (CNP) #145 confirmed she ordered STAT labs for Resident #146 on 08/06/23. CNP #145 confirmed she was not notified the labs had not been drawn STAT as ordered on 08/06/23. Interview on 08/10/23 at 10:37 A.M. with WN #131 confirmed WP #108 was not notified the STAT lab was not completed on 08/03/23 as ordered. Review of the facility policy, Change in the Residents Condition or Status, updated 11/2016, revealed the policy stated, it is the facility's policy to ensure the resident's attending physician and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 6 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 the residents authorized representative or interested family member are notified of changes in the resident's physical, mental, or psychosocial status. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 7 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of a Facility Reported Incident (FRI) investigation, staff interview, and facility policy review, the facility failed to report an allegation of physical abuse to the Ohio Department of Health (ODH) within two hours for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for abuse. The facility census was 44. Findings Include: Review of the medical record for Resident #35 revealed an admission date on 12/09/21. Medical diagnoses included encephalopathy, cognitive communication deficit, Alzheimer's Disease, anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had severely impaired cognition. Resident #35 required extensive assistance from two staff to complete Activities of Daily Living (ADLs). Review of the progress note dated 01/16/23 at 8:37 P.M. revealed Registered Nurse (RN) #130 entered Resident #35's room to administer medications. Resident #35's daughter was present at bedside. Resident #35 was compliant with taking medications initially however, when the resident's daughter approached the bed, and insisted the resident take his medications, Resident #35 attempted to expel the medication from his mouth. Resident #35's daughter placed her hand over the resident's mouth to prevent the resident from spitting the medications out. RN #130 offered to return at a later time and Resident #35 agreed however, the resident's daughter insisted Resident #35 take his medication. RN #130 attempted to administer two more medications. Resident #35 successfully took one pill but spit the other one out despite the resident's daughter holding her hand over Resident #35's mouth. Resident #35 accepted a drink of water despite a high state of distress. Review of the facility report incident (FRI) basic case information revealed the investigation was created on 01/17/23 at 4:27 P.M., 20 hours after the incident occurred. Interview on 08/09/23 at 6:15 P.M. with the Administrator and Regional Nurse (RGN) #144 confirmed RN #130 reported the incident to the Administrator immediately. The Administrator confirmed the allegation of physical abuse for Resident #35 was not reported to the Ohio Department of Health (ODH) until 01/17/23 and was not reported within two hours. The Administrator stated she was not aware that any abuse allegations needed to be reported within two hours and thought the allegation only needed to be reported within two hours if there was bodily injury. Review of the facility policy, Abuse, Mistreatment, Neglect, Injuries of Unknown Source, and Misappropriation of Resident Property, undated, revealed the policy stated, all allegations of abuse, neglect, misappropriation, injuries of unknown origin must be reported immediately to both the Administrator and to the Ohio Department of Health (ODH). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 8 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility failed to submit a new Pre-admission Screening/Resident Review (PASRR) once a resident received a new diagnosis of major depressive disorder. This affected one (Resident #37) of two residents reviewed for PASRR. The census was 44. Findings included: 1. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, sepsis, hypertension, sleep apnea, atrial fibrillation, heart failure, aortic aneurysm of unspecified site, kidney failure, and gastroesophageal reflux disease. Review of chart revealed Resident #37 was given a new diagnosis of major depressive disorder on 03/02/23. Review of Pre-admission Screening/Resident Review (PASRR) dated 03/07/22 revealed no evidence of Resident #37 having a mood disorder. Interview on 08/09/23 at 12:01 P.M. with Social Services Director #171 confirmed a new PASRR had not been completed to indicate Resident #37 had a new diagnosis of major depressive disorder. A policy for PASRR was requested on 09/09/23 at 4:16 P.M. but was not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 9 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Residents Affected - Few Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including personal hygiene. Resident #18 was totally dependent on one staff for bathing. Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities. Review of the care plan, revised 08/07/23, revealed Resident #18 had impaired ability to perform ADL care. Interventions included provide nail care and shampoo hair with showers per weekly schedule. Observation on 08/07/23 at 12:34 P.M. of Resident #18's feet revealed the resident's toenails were long, thick, jagged, and discolored. Interview on 08/07/23 at 12:34 P.M. with Resident #18 revealed her toenails sometimes bother her because they snagged her bed sheets. Resident #18 stated she would like to have her toenails trimmed and staff had not offered to complete toenail care for her since she was admitted to the facility. Interview on 08/09/23 at 8:53 A.M. with Resident #18 revealed she received a shower on 08/08/23 and no foot or toenail care was offered or provided. Interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed Resident #18's toenails were long, thick, jagged, and discolored with a yellow tint. STNA #146 confirmed Resident #18's toenails needed trimmed. STNA #146 stated she thought aides were allowed to trim fingernails but not toenails. Review of the facility policy, Fingernails/Toenails-Care of, dated 06/08/22, revealed the policy stated, it is the facility's policy to clean the nail bed, to keep nails trimmed, and to prevent infections. Based on record review, observation, interview, and policy review, the facility failed to ensure showers were completed for Resident #37 and failed to ensure toenail care was completed for Resident #18. This affected two (Resident #18 and #37) of two residents reviewed for activities of daily living (ADL). The facility census was 44. Findings included: 1. Record review revealed Resident #37 admitted to the facility on [DATE] with diagnoses including acute respiratory failure, sepsis, hypertension, sleep apnea, atrial fibrillation, heart failure, aortic aneurysm of unspecified site, kidney failure, and gastroesophageal reflux disease. Review of a minimum data set (MDS) completed on 05/06/23 revealed Resident #37 has a brief interview for mental status (BIMS) of 15 indicating he is cognitively intact, he requires an extensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 10 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm assist of two people for bed mobility, extensive assist of one person for toileting, and total dependence of one person for bathing. Review of a shower schedule revealed Resident #37 was scheduled to receive showers three times a week; one on Tuesday, one on Thursday, and one on Saturday during first shift. Residents Affected - Few Review of ADL documentation and shower sheets for January 2023 through August 10, 2023 revealed Resident #37 did not receive scheduled showers on January 14th or January 19th; February 4th, 18th, or 25th; March 9th or 18th; April 1st, 4th, 6th, 8th, 13th, 22, 27, or 29th; May 6th, 13th, 20th, or 27th; June 1st, 15th, 17th, 20th, or 27th; July 15th or 27th; and August 1st or 3rd. Interview on 08/07/23 at 10:30 A.M. with Resident #37 revealed he is supposed to receive showers every Tuesday, Thursday, and Saturday. Resident #37 did state the he refuses at times, but often is not offered his scheduled showers. Interview on 08/10/23 at 1:32 P.M. with Registered Nurse (RN) #144 confirmed Resident #37 did not receive several showers as scheduled. RN #144 stated each resident should receive a minimum of two showers a week, then additional showers per resident preference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 11 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure one resident (Resident #18) had a soft cervical collar placed when out of bed as ordered. Additionally, the facility failed to timely complete initial comprehensive wound assessments for one resident's (Resident #146) surgical wounds. The deficient practices affected two residents (Residents #18 and #146) of two residents reviewed for quality of care. The facility census was 44. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including personal hygiene. Resident #18 was totally dependent on one staff for bathing. Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities. Review of the physician orders dated August 2023 revealed Resident #18 had an order to wear soft collar when out of bed every shift dated 08/07/23. Review of the care plan, revised 08/07/23, revealed Resident #18 had impaired ability to perform ADL care. Interventions included resident to wear cervical collar when out of bed. Observation on 08/09/23 at 8:53 A.M. revealed Resident #18 was out of bed, sitting in her wheelchair without soft neck collar on. Interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed Resident #18 was out of bed and did not have a soft neck collar on as ordered. STNA #146 stated she was not sure if Resident #18 was supposed to have the collar on or not because she had been told different things. Review of the facility policy, Matrix: General Order Policy and Procedure, undated, revealed the policy stated, it is the facility's policy to follow the general order physician guidelines. 2. Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living. Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 12 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Illustration of Documentation and Measurements of Skin Areas dated 07/28/23 revealed Resident #146 had foot wounds identified. Review of the Wound Grid Documentation for the wound on the lateral top of Resident #146's left foot revealed the initial observation was dated 08/01/23 at 11:09 A.M. (four days after admission) and was completed on 08/07/23 at 1:20 P.M. Resident #146 was admitted with the surgical wound. Review of the Wound Grid Documentation for the wound on the top of Resident #146's left foot revealed the initial observation was dated 08/01/23 at 11:12 A.M. (four days after admission) and completed on 08/07/23 at 1:10 P.M. Resident #146 was admitted with the surgical wound. Interview on 08/10/23 at 10:37 A.M. with Wound Nurse (WN) #131 revealed if a resident was a new admission and had identified wounds upon admission, the wounds should be assessed one to two days after admission. Interview on 08/10/23 at 1:58 P.M. with WN #131 revealed the admitting nurse, Licensed Practical Nurse (LPN) #127, identified the surgical wounds on Resident #146's foot on the skin grid upon admission on [DATE] but did not complete a comprehensive assessment including measurements or a description of the wounds. WN #131 stated she added measurements to the skin grid later. WN #131 confirmed she did not complete a comprehensive assessment of the surgical wounds until 08/01/23 (four days after admission) because Resident #146 was admitted on the weekend which she does not work over the weekend and she was scheduled to work on the floor on Mondays so she was not available to complete a comprehensive assessment until Tuesday, 08/01/23. Interview on 08/10/23 at 2:45 P.M. with Regional Nurse (RGN) #144 confirmed the expectation would be for an initial comprehensive assessment of any wounds to be completed the same day as admission if possible. However, if a resident was admitted on the weekend with a treatment in place, the admitting nurse should note the areas and a full comprehensive assessment should be completed within 72 hours (three days) of admission. Review of the facility policy, Pressure Injuries: Assessment, Prevention & Treatment, undated, revealed the policy did not address non-pressure skin areas. No additional skin policies were provided by the facility that addressed non-pressure skin areas. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 13 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to timely complete initial comprehensive assessments of identified pressure injury areas for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of three residents reviewed for pressure ulcers. The facility census was 44. Residents Affected - Few Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, and Type II Diabetes Mellitus with foot ulcer. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living. Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds. The assessment did not indicate Resident #146 had any pressure ulcers. Review of the Wound Grid Documentation for the skin area on the right side of Resident #146's scrotum revealed the observation was opened on 07/28/23 at 6:01 P.M. by LPN #127, charting started on 07/29/23 at 11:20 A.M. by LPN #127, and completed on 08/08/23 at 9:13 A.M. by WN #131. The skin area was identified by LPN #127, however, a comprehensive assessment of the area was not completed until 08/03/23 (six days after admission) by WN #131. The area was described as a Stage I pressure injury by WN #131. Review of the Wound Grid Documentation for the skin area on Resident #146's right buttock revealed the observation was opened on 07/28/23 at 6:03 P.M. by LPN #127, charting started on 07/29/23 at 11:22 A.M. by LPN #127, and completed on 08/09/23 at 6:42 A.M. by WN #131. The skin area was identified by LPN #127, however, a comprehensive assessment of the area was not completed until 08/03/23 (six days after admission) by WN #131. The area was described as an unstageable pressure injury by WN #131. Review of the Wound Grid Documentation for the skin area on Resident #146's left buttock revealed the observation was opened on 07/28/23 at 6:04 P.M. by Licensed Practical Nurse (LPN) #127, charting started on 07/29/23 at 11:24 A.M. by LPN #127, and completed on 08/09/23 at 7:12 A.M. by Wound Nurse (WN) #131. The skin area was identified by LPN #127, however, a comprehensive assessment of the area was not completed until 08/03/23 (six days after admission) by WN #131. The area was described as an unstageable pressure injury by WN #131. Interview on 08/10/23 at 10:37 A.M. with Wound Nurse (WN) #131 revealed if a resident was a new admission and had identified wounds upon admission, the wounds should be assessed one to two days after admission. WN #131 confirmed a comprehensive assessment of the above skin areas was not completed until 08/03/23 (six days after admission). Interview on 08/10/23 at 2:45 P.M. with Regional Nurse (RGN) #144 confirmed the expectation would be for an initial comprehensive assessment of any wounds to be completed the same day as admission if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 14 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete possible. However, if a resident was admitted on the weekend with a treatment in place, the admitting nurse should note the areas and a full comprehensive assessment should be completed within 72 hours (three days) of admission. Review of the facility policy, Pressure Injuries: Assessment, Prevention & Treatment, undated, revealed the policy stated, it is the facility's policy to identify residents at risk for developing pressure injuries, implement interventions to prevent the development of pressure injuries and provide care for existing pressure injuries. Event ID: Facility ID: 366369 If continuation sheet Page 15 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #9 revealed an initial admission date of 11/16/20 with the latest readmission of 08/23/21 with the diagnoses including hypertension, major depressive disorder, anxiety disorder, sleep apnea, chronic obstructive pulmonary disorder, osteoarthritis, obesity, fibromyalgia, full incontinence of feces, weakness, dysphagia, retention of urine, hyperlipidemia, atrial fibrillation, congestive heart failure, dyskinesia of esophagus, diverticulum of esophagus, diverticulosis of intestine, dysphagia, hypothyroidism, cerebral infarct, schizophrenia, dementia and gastro-esophageal reflux disease. Review of the plan of care dated 11/16/20 revealed the resident was incontinent of bladder and was at risk for altered dignity, skin breakdown and urinary tract infection (UTI). Interventions included administer medication per physician orders, assess quarterly and as needed for any changes in elimination patterns, check and provide incontinence care as needed in elimination patterns, check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, maintain resident dignity when checking/providing incontinence care, observe protective pads/briefs for skin tolerance, observe/report any noted redness, excoriation or open areas with incontinence care, observe protective pads/briefs for skin tolerance, observe/report any signs/symptoms of UTI, provide physical support/assist for toileting safety as indicated for resident. Review of the plan of care dated 11/16/20 revealed the resident had bowel incontinence and was at risk for altered dignity, skin breakdown, diarrhea and constipation. Interventions included administer medication per physician orders, assess quarterly and as needed for any changes in elimination patterns, check and provide incontinence care as needed in elimination patterns, check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, maintain resident dignity when checking/providing incontinence care, observe/record bowel movements daily for amount/consistency, observe/report any diarrhea, constipation, change in bowel movement, abdominal distention and/or discomfort, observe protective pads/briefs for skin tolerance, observe/report any noted redness, excoriation or open areas with incontinence care, observe protective pads/briefs for skin tolerance and provide physical support/assist for toileting safety. Review of the monthly physician orders for August 2023 identified orders dated 08/23/21 for barrier cream to buttocks after each incontinent episode, record bowel movement every shift, and on 04/26/23 toileting extensive assist of one and incontinent of bowel and bladder. On 08/07/23 at 11:08 A.M., observation/interview with Resident #9 revealed she had not been changed since night shift and she was really wet. Resident #9 reported she had her call light on for a while and asked to verify it was working. On 08/07/23 at 11:15 A.M., interview with State Tested Nursing Assistant (STNA) #114 answered the light call light and verified the resident was saturated with urine and had not been provided incontinence care since night shift ending at 6:00 A.M. Review of the facility policy, Perineal Care, dated 06/07/22, revealed the policy stated, it is the facility's policy to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 16 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 No additional policies related to toileting or incontinence care were provided by the facility. Level of Harm - Minimal harm or potential for actual harm Based on record review, observations, resident and staff interviews, and facility policy review, the facility failed to complete timely incontinence care and toileting assistance for two residents (Residents #9 and #18). The deficient practice affected two residents (Residents #9 and #18) of two reviewed for bowel and bladder. The facility census was 44. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from two staff to complete Activities of Daily Living (ADLs), including toileting. Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities. Resident #18 was frequently incontinent of bowel and bladder. Review of the care plan, revised 08/07/23, revealed Resident #18 was incontinent of bladder and was at risk for altered dignity, skin breakdown, and urinary tract infection (UTI). Interventions included check and provide incontinence care as needed, apply moisture barrier cream after each incontinent episode, provide physical support/assistance for toileting safety as indicated for resident. Observation and interview on 08/09/23 at 8:53 A.M. with Resident #18 in her room. The resident was out of bed and sitting in her wheelchair next to her bed. Resident #18 stated she had been waiting approximately an hour for staff to assist her onto bed pan. Resident #18 stated she had not had an accident but had been holding it for a long time. Resident #18 stated it took two staff to assist her out of her wheelchair, transfer her back into bed, and place her on the bedpan. Interview on 08/09/23 at 9:30 A.M. with State Tested Nurse Aide (STNA) #150 confirmed Resident #18 requested to go to the bathroom this morning, approximately 45 minutes ago. STNA #150 stated she had been feeding another resident breakfast and forgot to inform the other aide that Resident #18 needed to use the bedpan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 17 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to ensure one resident (#34) received timely meal assistance. The facility also failed to ensure one resident's (#18) fluids were accessible. Additionally the facility failed to provided one resident (#9) the physician ordered two handled cup with meals. This affected one ( Resident #34) of one resident reviewed for nutrition, one ( Resident #18) of one resident received for hydration and one ( Resident #9) of 13 sampled residents. The facility census was 44. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #34 revealed an initial admission date of 05/20/21 with the diagnoses including contracture of muscle, multiple sites, dementia, malignant neoplasm of female breast, diabetes mellitus, hyperlipidemia, vitamin D deficiency, anxiety disorder, trigeminal neuralgia, aortic valve stenosis, aortic valve insufficiency, peripheral vascular disease, depression, osteoporosis, hypertension, hematuria and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a severe cognitive deficit. The resident required extensive assistance of two for bed mobility, transfers, and eating. Review of the plan of care dated 07/11/23 revealed the resident had an impaired ability to perform or participate in daily activities of daily living (ADL) care related to impaired mobility, dementia, breast cancer, diabetes mellitus, peripheral vascular disease and osteoporosis. Interventions included offer resident verbal cues if needed for chewing and swallowing or to finish eating and offer assistance with feeding if needed. Review of the physician orders for August 2023 identified an order dated 08/11/23 eating extensive assistance of one. Observation of the 100 hallway meal tray delivery on 08/07/23 revealed Resident #34 was delivered her tray at 12:26 P.M., the food was set on the bedside tray and the aide exited the room. State Tested Nursing Assistant (STNA) entered the room at 12:50 P.M. to feed the resident. The plate with the warmer and lid had a piece of garlic bread. The green beans and the Florentine stuffed shell with marinara was in a bowl with a plastic lid. The tray also had an ice cream which was melted. Registered Nurse (RN) #131 instructed the aide to warm the food up and the resident was supposed to be in the dining room for meals. The aide revealed the microwave on the unit no longer worked and asked if she should take the food to the kitchen to be warmed. RN #131 verified the resident should have been fed when the meal tray was delivered. On 08/07/23 at 3:36 P.M., interview with the resident's family member revealed she had a problem with the facility assisting the resident with meals and had to tell the facility to feed her mother. 2. Review of the medical record for Resident #18 revealed an admission date on 07/14/23. Medical diagnoses included Parkinson's Disease, nondisplaced Type II dens fracture (a bone in the spine), fracture of phalanx of right thumb, fracture of sacrum, and rheumatoid arthritis. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #18 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 18 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had intact cognition and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #18 required extensive assistance from one staff to complete eating task (how resident eats and drinks). Resident #18 had functional limitations in range of motion (ROM) and impairments on both side of upper and lower extremities. Review of physician orders dated August 2023 revealed Resident #18 had a diet order for a regular diet with thin liquids and drinks in green lidded/handled cups dated 07/21/23. Review of care plan, revised 08/07/23, revealed Resident #18 was at risk for altered nutrition. Interventions included drinks in green lidded/handled cups with long straws. Observations on 08/07/23 at 12:45 P.M., 08/08/23 at 10:02 A.M., 08/08/23 at 3:15 P.M., 08/08/23 at 5:41 P.M., and 08/09/23 at 8:53 A.M. revealed Resident #18 had fluids in a green lidded/handled cup with a straw as ordered but the fluids were not within reach of the resident to be able to get a drink. Interview on 08/08/23 at 10:24 A.M. with Resident #18 confirmed fluids were on her bedside table but she was not able to reach it to get a drink. Resident #18 stated, it is hard for me to talk because I'm dry. Interview on 08/09/23 at 8:53 A.M. with Resident #18 confirmed fluids with straw were not within her reach to be able to take a drink. Resident #18 stated she went for long periods of time with drinking anything. Resident #18 stated she was thirsty at the time of the interview. Observed Resident #18 attempt to reach lidded/handled cup with straw to take a drink and was not able to reach the cup. Resident #18 reported staff had checked on her approximately 30 minutes ago but did not offer to assist resident with getting a drink at that time. Interview on 08/09/23 at 9:16 A.M. with State Tested Nurse Aide (STNA) #146 confirmed fluids were not within reach of Resident #18. Review of the facility policy, Hydration, undated, revealed the policy stated, resident's shall be offered sufficient fluids to maintain proper hydration and health. 3. Record review revealed Resident #9 admitted to the facility on [DATE] with diagnoses including left femur fracture, hypertension, major depressive disorder, chronic obstructive pulmonary disease, hypokalemia, anxiety disorder, sleep apnea, atrial fibrillation, diastolic congestive heart failure, schizophrenia, unspecified dementia, and hypothyroidism. Review of minimum data set (MDS) from 05/20/23 revealed Resident #9 requires set-up help with supervision for meals. Review of care plan revealed Resident #9 should use adaptive equipment as ordered for her nutritional status. Review of orders revealed an order for Resident #9 to use a two-handled cup with meals dated 05/05/23. Observation on 08/09/23 at 5:07 P.M. revealed STNA #112 provided Resident #9 with tea glasses of sweet tea in regular cups. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 19 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Minimal harm or potential for actual harm Interview on 08/09/23 at 5:07 P.M. with STNA #112 confirmed Resident #9 was given regular cups instead of a two-handled cup. A policy for adaptive equipment states residents shall be offered assistive devices that enable them to be more independent. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 20 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #10 revealed an initial admission date of 08/31/22 with the latest readmission of 12/26/22 with the diagnoses including metabolic encephalopathy, gram-negative sepsis, urinary tract infection (UTI), acute kidney failure, hypertensive urgency, acute respiratory failure with hypoxia, personal history of COVID-19, heart failure, hypertension, diabetes mellitus, hypothyroidism, Vitamin D deficiency, hyperlipidemia, alcohol dependence in remission, major depressive disorder, subacute combined degeneration of spinal cord, benign neoplasm of major salivary gland, chronic obstructive pulmonary disease, cataract, congestive heart failure, aneurysm, contracture of muscles, panlobular emphysema, gastroesophageal reflux disease (GERD), cerebral vascular accident (CVA), urine retention, insomnia, visual hallucinations, auditory hallucinations, anxiety disorder, restlessness and agitation and Bell's palsy. Review of the resident's quarterly MDS assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The resident received insulin, antipsychotic, antianxiety, antidepressant medications. The assessment indicated the resident received the antipsychotic medication on a daily basis and a gradual dose reduction (GDR) had not been attempted and the physician had not documented the GDR clinically contraindicated. Review of the pharmacy recommendation dated 02/18/23 revealed the pharmacist recommended a review of the resident's blood pressure medication to discontinue either Doxazosin 1 mg daily or Losartan-Hydrochlorothiazide 100-12.5 mg. The physician addressed the recommendation on 03/27/23, more than 30 days after the recommendation was made. On 08/10/23 at 9:54 A.M., interview with Regional Nurse #144 verified the 02/18/23 pharmacy recommendation was not addressed for more than 30 days following the recommendation. 3. Review of the medical record for Resident #28 revealed and admission date on 01/02/23. Medical diagnoses included acute respiratory failure with hypoxia, dementia without behavioral disturbance, anxiety disorder, and major depressive disorder-recurrent. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #28 had severely impaired cognition and scored a four out of 15 on the Brief Interview for Mental Status (BIMS) assessment. No behaviors were noted in the assessment. Resident #28 required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). Resident #28 received daily antipsychotic and antidepressive medications. Antipsychotics were received on a routine basis and a GDR was documented as contraindicated on 01/16/23. Review of the pharmacy recommendation dated 02/18/23 revealed Resident #28's psychotropic medications were reviewed to see if a trial dose reduction or discontinuation could be attempted. Resident #28 received Aripiprazole (an antipsychotic medication) 7 mg daily at night, Sertraline (an antianxiety medication) 25 mg daily, and Hydroxyzine (an antianxiety medication) 10 mg every eight hours as needed. No hallucinations, behavioral symptoms, rejection of care, or wandering was noted on the MDS assessment for Resident #28. The recommendation was to reduce Aripiprazole to 5 mg at night and continue Hydroxyzine as needed for 90 days due to only being used once in previous two weeks for anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 21 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 The pharmacy recommendation was not addressed until 03/27/23 (over a month later). Level of Harm - Minimal harm or potential for actual harm Interview on 08/10/23 at 9:50 A.M. with Regional Nurse (RGN) #144 confirmed the pharmacy recommendation was not addressed for over a month. RGN #144 stated the Director of Nursing Services (DNS) was off from work during that time and no other staff caught that pharmacy recommendations had not been addressed until the DNS returned to work the end of March. Residents Affected - Few Review of a policy titled Consultation Pharmacy Reports from May 2020 revealed the facility should respond to the pharmacy recommendation in a timely manner. Review of the facility policy, Documentation and Communication of Consultant Pharmacist Recommendations, dated 05/2020, revealed the policy stated, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapies are communicated to those with authority and/or responsibility to implement the recommendations and are responded to in an appropriate and timely fashion. Comments and recommendations concerning medication therapy are communicated in a timely fashion. The timing of these recommendations should enable a response prior to the next Medication Regimen Review (MRR). Based on record review and interview, the facility failed to address pharmacy recommendations within thirty days and did not follow up on recommended labs. This affected three (Resident #9, #10, and #28) of three residents reviewed for medication regiment reviews. The facility census was 44. Findings included: 1. Record review revealed Resident #9 admitted to the facility on [DATE] with diagnoses including left femur fracture, hypertension, major depressive disorder, chronic obstructive pulmonary disease, hypokalemia, anxiety disorder, sleep apnea, atrial fibrillation, diastolic congestive heart failure, schizophrenia, unspecified dementia, and hypothyroidism. Review of minimum data set (MDS) from 05/20/23 revealed Resident #9 was cognitively intact and had no behaviors. Review of care plan from 11/16/20 revealed Resident #9 takes psychotropic medications including an antidepressant, antianxiety, and antipsychotic. Review of orders revealed Resident #9 was prescribed buspirone (an antianxiety medication) 10 milligrams (mg) three times a day for sadness/withdrawn, hydroxyzine (an antihistamine) 25 mg twice a day for tearful, easily irritated, Zyprexa (an antipsychotic) 5 mg at bedtime for auditory and visual hallucinations, trazodone (an antidepressant) 50 mg at bedtime to promote sleep, effexor (antidepressant) once a day 150 mg for tearful, sad, withdrawn, and effexor 75 mg at bedtime for tearful, sad, withdrawn. Review of a pharmacy recommendation from 02/18/23 revealed a recommendation to decrease Zyprexa from 7.5 mg to 5 mg. The recommendation was not reviewed until 03/27/23. Review of a pharmacy recommendation from 07/19/23 revealed a recommendation to decrease Zyprexa from 5 mg to 2.5 mg or to obtain genesight testing for medication optimization purposes. Provider declined the recommendation for decrease and opted for the genesight testing on 07/20/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 22 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Interview on 08/09/23 at 5:21 P.M. with Registered Nurse (RN) #144 confirmed the pharmacy recommendation was not reviewed within thirty days. RN #144 confirmed despite provider opting for the genesight testing, an order was never obtained for the labs and the facility had not followed up on genesight testing to be completed. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 23 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility facility to ensure medications were properly stored and labeled. This affected Resident #20 using the Lantus insulin pen and had the potential to affect 27 residents (#1, #2, #4, #5, #7, #9, #10, #11, #13, #14, #17, #19, #20, #21, #22, #25, #26, #27, #29, #30, #34, #36, #37, #38, #40, #76 and #94) who reside on the 100 unit. The facility census was 44. Findings Include: 1. On 08/10/23 at 3:05 P.M., observation of the 100 unit medication cart revealed one Lantus insulin pen laying in the drawer with no name or date on the insulin pen. The Lantus insulin pen had been pulled from the emergency drug kit (EDK). Further observation revealed a Lispro Insulin pen laying in the drawer with no name or date on the insulin pen. The Lispro insulin pen was also pulled from the EDK. Interview with Licensed Practical Nurse (LPN) #127 at the time of the observation revealed she was unsure what resident the insulin pens were pulled from the EDK. She removed six empty clear plastic bags from the insulin drawer on the medication cart and revealed the Lantus was pulled for Resident #20 but was unsure who the Lispro belonged to but verified she used the Lantus insulin pen. 2. On 08/10/23 at 3:10 P.M., observation of the 100 unit medication storage refrigerator located in the 100 unit medication storage room revealed one vial of Tuberculin solution opened with no date when the vial had been opened. Registered Nurse (RN) #131 verified the vial of Tuberculin solution was not dated and should have been dated when opened. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 24 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of lab results, staff interview, and review of the facility laboratory agreement, the facility failed to obtain STAT (immediate) labs as ordered for one resident (Resident #146). The deficient practice affected one resident (Resident #146) of one reviewed for laboratory testing. The facility census was 44. Residents Affected - Few Findings Include: Review of the closed medical record for Resident #146 revealed an admission date on 07/28/23. Resident #146 was sent out to the hospital and discharged from the facility on 08/07/23. Medical diagnoses included acute osteomyelitis left ankle and foot, sepsis, Type II Diabetes Mellitus with diabetic neuropathy, Type II Diabetes Mellitus with foot ulcer, and chronic kidney disease stage 3b. Review of the Five Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #146 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #146 required extensive assistance from one staff to complete Activities of Daily Living. Resident #146 had impaired skin. Resident #146 had an infection of the foot and surgical wounds. Review of the physician orders for August 2023 revealed Resident #146 had the following orders: STAT WBC (white blood cell) dated 08/03/23 and STAT CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) dated 08/05/23. Review of the progress notes revealed on 08/03/23 at 2:33 P.M., the Assistant Director of Nursing (ADON)/Wound Nurse (WN) #131 documented wound rounds were completed with Wound Physician (WP) #108. There was concern over resident's left foot. STAT WBC was ordered. On 08/06/23 at 12:25 P.M., a note indicated, spoke to lab at this time regarding STAT labs that were put into the system. They stated they had no coverage for this STAT lab and labs were to be drawn on 08/07/23 in the morning. Review of the care plan dated 07/28/23 revealed Resident #146 had a wound infection. Interventions included obtain and report diagnostic testing and lab work per order. Review of lab results for Resident #146 revealed labs were collected on 08/04/23 and 08/07/23 respectively. Interview on 08/09/23 at 6:10 P.M. with the Administrator and Regional Nurse (RGN) #144 confirmed Resident #146 had orders for STAT labs and they were not collected as ordered. RGN #144 stated the facility was currently looking into changing lab providers due to the current lab not being able to accommodate the facility's needs, especially on the weekends. Review of the Nursing Facility Laboratory Agreement, dated 02/02/18, revealed the lab provided STAT (life threatening situation) service 24 hours per day, 365 days per year. Laboratory STAT testing would be reported within five hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 25 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and facility policy review, the facility failed to maintain infection control practices in the manner to prevent the potential spread of infection in the area of pressure ulcer dressing change and catheter care. This affected one resident (#20) of two residents reviewed for pressure ulcers and one resident (#37) of one resident reviewed for catheter. The facility census was 44. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #20 revealed an initial admission date of 08/06/23 with the diagnoses including acute respiratory failure, abnormal posture, disorder of pituitary gland, vitamin D deficiency, major depressive disorder, anxiety disorder, chronic pain syndrome, chronic kidney disease, hypertension, dementia, cerebrovascular accident with hemiplegia, chronic obstructive pulmonary disease, diabetes mellitus, polyneuropathy, gastro-esophageal reflux disease, disorders of diaphragm, bilateral foot drop, colostomy status, osteoarthritis, bipolar disorder, contracture of left hand and contracture of left wrist. Review of the plan of care dated 08/18/22 revealed the resident was at risk for skin breakdown related to impaired mobility, diabetes mellitus, urinary incontinence, hemiplegia, steroid therapy, renal disease, poor sensory perception, friction concerns, shearing concerns, refuses splints, heel protectors, [NAME] boots, resists showers/baths, turning/repositioning, elevating heels, ostomy care, incontinence care and getting out of bed. Interventions included apply bilateral PRAFO boots up to eight hours as tolerated four to seven days per week, check skin before application and upon removal, assist resident as needed with turning and repositioning frequently when in bed and/or shift weight to reposition when in chair as tolerated, encourage resident not to slide/scoot when in bed or chair, encourage/assist the resident to float heels as tolerated, observe resident for any incontinence episodes and provide incontinence care as needed, apply protective barrier after each incontinence episode, observe/report non-compliance with preventative skin care and notify physician as needed, observe/report any signs/symptoms of skin irritation, provide nutritional support as ordered and utilize air mattress. Review of the plan of care dated 09/06/23 revealed the resident has a surgical wound to the coccyx related to impaired mobility, diabetes, urinary incontinence, COPD, poor nutritional intake, poor sensory perception, friction concerns, shearing concerns, history of impaired skin, resists showers/baths, turning, elevating heels and potential for wound pain. Interventions included continue with preventative care plan measures to prevent further skin breakdown, observe wound for any redness, warmth, drainage, odor and report to physician as needed, observe/report any non-compliance/rejection of care for wound management, notify physician as needed and treatment as ordered. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of the mood and behavior revealed the resident had not rejected any care. The resident required extensive assistance of two staff for bed mobility, transfers and toilet use. The resident had an ostomy and was frequently incontinent of bladder. The assessment indicated the resident was at risk for skin breakdown and had an unhealed stage III pressure ulcer to the coccyx and a surgical wound. The facility implemented the interventions pressure reducing device to bed, nutrition or hydration intervention, pressure ulcer/injury care, surgical wound care, application of nonsurgical dressing and application of nonsurgical dressings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 26 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the monthly physician orders for August 2023 identified orders dated 01/19/23 apply Triad topically to coccyx every shift, 07/27/23 cleanse wound to coccyx with normal saline (NS), pat dry, apply calcium alginate with silver to hole and undermining, cover with an island adhesive dressing daily, 08/07/23 apply bilateral PRAFO boots up to eight hours as tolerated, check skin before application and upon removal, 08/08/23 cleanse wound to coccyx with NS, pat dry, apply calcium alginate with silver to hole and undermining, cover with an island adhesive dressing as needed, complete weekly skin checks every Friday and encourage resident to float heels while in bed. Review of the most recent weekly wound grid dated 08/03/23 revealed the wound was classified as a surgical wound measuring 2.8 centimeters (cm) by 1.5 cm by 0.5 cm with tunneling/undermining measuring 0.3 cm from 6 o'clock to 1 o' clock. The wound was described as having light serosanguinous exudate. The assessment had no description of the wound. On 08/09/23 at 11:06 A.M., interview with Registered Nurse (RN) #131 revealed the resident was admitted to the facility with a Stage II pressure ulcer but that had healed. She revealed the resident's current wound began as a scab and the wound physician did a biopsy. She revealed the scab was pulled off with a bed pan and the wound had progressed but remained classified as a surgical wound. On 08/09/23 at 11:20 A.M., observation of RN #131 provide the physician ordered treatment to the wound to the resident's coccyx revealed the RN placed paper towels on the bottom right side of the bed and placed the required supplies on the barrier. She removed the soiled dressing, walked around the bed and picked up the resident's trash can and placed on the floor on the right side of the bed. The RN then changed gloves without washing or sanitizing her hands. She then picked up a bullet of normal saline (NS) opened the bullet, sat the bullet on the resident's sheet. The RN then changed her gloves and cleansed the wound with NS and a split drain sponge. The RN then pat the wound dry using a drain sponge. The RN then changed her gloves without washing or sanitizing her hands, cut a square piece of calcium alginate with silver and packed the wound using a sterile Q-tip. The RN revealed the resident had undermining from 2 o'clock to 6 o'clock. The RN then changed her gloves without washing or sanitizing her hands and covered the wound with an island dressing. On 08/09/23 at 11:38 A.M., interview with RN #131 verified the lack of the handwashing during the dressing change resulting in the potential spread of infection to the wound. Review of the facility policy titled, Dressings, Dry/Clean, not dated reveled the purpose of the procedure was to provide guidelines for the application of dry dressings. Steps in the procedure include: adjust bedside stand to waist level, clean bedside stand, Establish a clean field. place the cleaned equipment on the bedside stand, arrange the supplies so they can be easily reached, tape a biohazard or plastic bag on the bedside stand or open on the bed, pull strips of tape adequate for securing dressing at the end of the procedure and add date, time and initials, place on edge of bedside table to enable easy access when needed, adjust the height of the bed to waist level, position resident and adjust clothing to provide access to affected area, wash and dry your hands thoroughly, put on clean gloves, loosen tape and remove soiled dressing, pull glove over dressing and discard into plastic or biohazard bag, wash and dry your hands thoroughly, open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface, using clean technique, open other products, pour prescribed solution over the dry clean gauze into clean basin section of tray, put on clean gloves, assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage, cleanse the wound, use a syringe to irrigate the wound, if ordered, if using gauze, use a clean gausses for each cleansing stroke, clean from the least contaminated area to the most contaminated area, use dry gauze to pat the wound dry, wash and dry hands thoroughly, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 27 of 28 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few apply the ordered dressing and secure with tape, discard disposable items into the designated container, remove disposable gloves and discard into designated container and wash and dry your hands thoroughly. 2. Review of the medical record for Resident #37 revealed an initial admission date of 09/30/22 with diagnoses including atrial fibrillation, congestive heart failure, sepsis, urinary tract infection, retention of urine and obstructive and reflux uropathy. Review of the plan of care dated 05/10/22 revealed the resident had an alteration in elimination related to Foley catheter. Interventions included change catheter bag per policy, change Foley catheter per physician order, irrigate catheter per physician order, Foley catheter care every shift and/or per policy, keep drainage bag below bladder and off the floor, observe for signs of UTI, use leg strap as needed to prevent tubing from pulling and position tubing so resident not sitting or lying on it. Review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. The resident required extensive assistance of one with toileting. The assessment indicated the resident had an indwelling urinary catheter. Review of the indwelling urinary catheter observation dated 08/07/23 revealed the resident had the catheter related to untreatable urinary blockage. Review of the monthly physician orders for August 2023 identified orders dated 10/01/22 catheter output every shift, 10/12/22 catheter care, change catheter as needed, change urinary collection bag monthly, 10/25/22 flush catheter with 60 milliliters (ml) of normal saline (NS) every shift and as needed, 03/27/23 18 FR Coude catheter and 18 FR Coude Foley catheter to be changed monthly. On 08/09/23 at 10:40 A.M., observation of Regional Nurse #144 and State Tested Nursing Assistant (STNA) #114 provide the physician ordered catheter care revealed they washed their hands, set-up supplies on barrier on bedside table. STNA #114 obtained a basin of water, covered the resident with a bath blanket and pulled the resident's incontinence brief down. The STNA sanitized her hands and donned clean gloves. The STNA obtained a wet washcloth and placed peri-wash on the cloth. The STNA then washed the Foley catheter back and forth using the same section of the cloth. Review of the policy titled, Catheter Care, Urinary, last updated 11/19 revealed it was the facility's policy to prevent infection of the resident's urinary tract by implementing the following procedures. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 28 of 28